Just the other day, a paper from Archives of Surgery reported that patients who have existing DNR orders have a higher postoperative mortality rate than patients who do not. This, of course was not surprising since people with DNR status are usually old and sick. The paper did receive some media attention with routine “churnalistic”* coverage. [HealthDay News, Medscape, MSN Health]
Having read the paper with mild interest, I didn’t think too much about it until yesterday when the May issue of the journal Critical Care Medicine [CCM] arrived. In it was a paper which is very similar to the Archives article. Let’s compare the two papers. The Archives paper was entitled “High mortality in surgical patients with do-not-resuscitate orders: analysis of 8256 patients,” and the CCM paper “Pre-existing do-not-resuscitate orders are not associated with increased postoperative morbidity at 30 days in surgical patients.”
Both papers used data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Database for the years 200-2008. The Archives paper found some 4128 DNR patients while the CCM paper found only 2199. Both studies matched the DNR patients with non-DNR patients who had similar operations and demographics.
Both papers found that DNR patients were a little more than twice as likely to die within 30 days than non-DNR patients, but the mortality rates were markedly different. The Archives mortality rates were 23.1% for the DNR and 8.4% for the non-DNR versus the CCM cohorts which were 12.5% and 5.2% respectively.
The Archives paper noted a significantly higher rate of major complications for the DNR patients with no difference in minor complications whereas the CCM paper reported that the DNR patients actually had significantly fewer wound infections and no difference in the major complication rate.
I could go on but I think you get the idea. Both sets of authors did mention that their studies could be confounded by the limitations of retrospective studies and the use of an administrative database, such as the NSQIP.
What is not clear and certainly beyond my ability to explain, are the marked discrepancies in the number of patients found with DNR orders when the time period of both studies was identical and the substantial differences in mortality and complication rates.
Bottom line. Although they are at a higher risk of death, DNR patients may undergo necessary surgical procedures with a reasonable expectation of success.
*Churnalism is a news article that is published as journalism, but is essentially a press release without much added